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indication
T1 tumors at high risk of progression (high grade, multifocality, CIS, and tumor size, )
In all T1 patients failing intravesical therapy
muscle-invasive bladder cancer T2-T4a, N0-Nx, M0
BCG-resistant Tis extensive papillary disease
performance status and age influence the choice of primary therapy, as well as type of urinary diversion with cystectomy being reserved for younger patients without concomitant disease and better performance status
Timing and delay of cystectomy
delay of treatment beyond 90 days of primary diagnosis caused a significant increase in extravesical disease (81 vs 52%)
Before cystectomy, the patient should be counselled adequately
regarding all possible alternatives, and the final decision should be based on a consensus between
patient and surgeon.
Technique and extent
prostate and seminal urothelial cancer in the prostate was detected in 33% in23-54% of patients a prostate cancer is found
uterus and adnexa in women spare seminal vesicles and the
prostatic capsule
Role of Lymphadenectomy provides insight into the local extent In limited nodal burden increase
survival
dissection of regional lymph nodes.
There is a substantial amount of literature about the extent of lymphadenectomy.
Yet, data regarding its clinical significance are controversial
In retrospective studies extended lymphadenectomy (removal of the
obturator, internal, external, common iliac and presacral nodes as well as
nodes at the aortic bifurcation) has been reported to improve survival
standard lymph node dissection
genitofemoral nerve laterally internal iliac artery medially Cooper ligament caudally, and the crossing of the ureter at
the common iliac artery cranially
Ileal Conduit
It is simplest type of conduit diversion to perform and isassociated with the fewest intraoperative and immediatepostoperative complications
Colon Conduit
transverse colon is used when one wants to be surethat the segment of conduit employed has not been irradiated
sigmoid conduit is a good choice in patients undergoing a pelvic exenteration who will have a colostomy
Contra-indications continent urinary diversion
• Debilitating neurological and psychiatric illnesses.
• Limited life expectancy.• Impaired liver or renal function.• Transitional cell carcinoma of the
urethral margin or other surgical margins